OhioHealth R.Ph.s win $50,000 for ADE program

Imagine being awarded a cool $50,000. That's what pharmacists at OhioHealth, a not-for-profit healthcare organization, nabbed for designing a program that reduced by 51% the adverse drug event (ADE) rate for the eight hospitals in its network. This was the first Award for Excellence in Medication-Use Safety offered by ASHP's Research & Education Foundation and sponsored by the Cardinal Health Foundation.

"We used 'trigger methodology' to help us focus on where the harm was and take steps to change how we did things," said Thomas Sherrin, R.Ph., OhioHealth's corporate director of clinical resource management. "Identifying ADEs through voluntary reporting simply wasn't enough. We wanted to use what we learned as a means to improve how we conducted medicine."

Hospitals are increasingly using sentinel events, or triggers, to initiate chart reviews to determine whether an ADE has occurred. Triggers might include orders of certain drugs, such as diphenhydramine for an allergic reaction; orders for antidotes, such as vitamin K for delayed blood clotting; certain abnormal laboratory values, such as a possible hypoglycemic reaction; or abrupt stop orders, as might occur from apparent oversedation. OhioHealth pharmacists adopted mechanisms to consistently identify ADEs. They also developed measures that created systematic changes in the way physicians prescribe by providing a platform to share best practices across the system, said Sherrin.

Taking the data gathered through trigger methodology, the OhioHealth R.Ph.s developed a series of interventions to reduce ADEs. Among them were education, identification of physician champions to encourage adherence to procedural change, anticoagulation monitoring by pharmacists, the posting of notices on the doors of rooms housing patients with reduced cognitive skills resulting from narcotics, and chart-based treatment algorithms to monitor for hypoglycemia. Other key outcomes include ongoing validation of a tool to classify the severity of reported ADEs and the creation of a systemwide full-time medication safety coordinator.

"Their work was extremely well conceived," commented Stephen Allen, R.Ph., executive VP/CEO of the ASHP foundation. "It demonstrates superb leadership by pharmacists of a very successful initiative that made tangible improvements." The pharmacists not only turned data into improved practice, they further refined the trigger methodology, said Allen. "They took what they had and looked forward, not just retrospectively," he explained. "It led to cultural change."

Current trigger methodology started with customized software developed in the early 1990s by David Classen, M.D., and others. Classen, now at the University of Utah, developed a method involving electronic examination of patient records; once a trigger was identified, a manual chart review ensued to determine whether an ADE had occurred. The chart reviews in turn led to examination of possibly adverse treatment patterns and sometimes a specific patient intervention.

Researchers found Classen's method costly and time-consuming. It requires a significant investment in software and expertise; those studying the charts had to have the medical experience necessary to differentiate between an ADE and appropriate medication use. "Most current efforts ... use retrospective chart review to detect ADEs," said Classen in an editorial about patient safety in the Journal of the American Medical Association, March 5, 2003. "Attention should be focused on the critical need to develop new methods to improve the detection of ADEs and other adverse events."

That's what OhioHealth did, building on work done in the late 1990s by the Institute for Healthcare Improvement in Boston and by researchers at the Mayo Health System in Eau Claire, Wis., who modified Classen's electronic trigger tool into a chart-based tool. Mayo researchers identified 24 specific triggers, reflecting a change from quantifying medication errors to measuring harm.

The OhioHealth pharmacists took the methodology another step, simplifying the process into seven specific triggers for three classes of drugs: anticoagulants, opioids, and insulin. Then, following a three-month chart review, each hospital took one drug class—usually the area where it experienced the highest number of triggers—to focus on improvement and ADE reduction.

"We wanted to identify high-risk medications—areas where specific steps could be taken to improve patient safety. It is essential that hospital pharmacists focus on improving medication-use safety systemwide," Sherrin said.

For further information about OhioHealth's program, Sherrin can be contacted at (614) 562-1568.